| NPI | 1609156777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: KY 9145) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OH 30023551) |
| 1223G0001X Dentist General Practice (Licence: IN 12011881A) | |
| Enumeration Date | 2011-08-22 |
| Last Update Date | 2016-03-01 |